injury report - SUNY Upstate Medical University

Section E - Return to Work (cont):Item 2: If you have since returned to work, check Yes. Also indicate on what date you started working again, as well as if youhave returned to your Normal Duties or if you are on Limited or Restricted Duty. (If you have not returned to your fullpre-injury or illness work duties, then you are on Limited Duty.)Item 3: If you have returned to work, indicate who you are working for now.Item 4: Enter your gross pay (before tax pay) per pay period for the job you are working at now. Indicate how often you arereceiving a paycheck (weekly, bi-weekly, etc.).Section F - Medical Treatment for This Injury or Illness:Item 1: If you did not receive medical treatment for this injury/illness, check None Received and skip to item 5. Otherwise,enter the date you first received treatment for this injury/illness and complete the rest of this section.Item 2: Check if you were first treated on the job for this injury or illness.Item 3: Check the location where you first received off site medical treatment for your injury or illness. Include the name andaddress of the facility as well as the phone number (including area code).Item 4: If you are still receiving ongoing treatment for the same injury or illness, check Yes and indicate the name andaddress of the doctor(s) providing treatment as well as the phone number (including area code); otherwise check No.Item 5: If you believe you already had an injury to the same body part or a similar illness, check Yes and indicate if you weretreated by a doctor for this injury or illness. If you were treated by a doctor, indicate the name(s) and address(es) of thedoctor(s) whom provided care and complete and file Form C-3.3 together with this form.Item 6: If you had a previous injury or illness, check if your previous injury or illness was work-related. If Yes, check ifthe injury or illness happened while working for your current employer.Sign Form C-3 in the place provided for "Employee's Signature on page 2, print your name, and enter the date you signed theform. If a third-party is signing on behalf of the employee, that person should sign on the second signature line. If you havelegal representation, your representative must complete and sign the attorney/representative's certification section on thebottom of page 2.What Every Worker Should Do in Case of On-The-Job Injury or Occupational Disease:1. Immediately tell your employer or supervisor when, where and how you were injured.2. Secure medical care immediately.3. Tell your doctor to file medical reports with the Board and with your employer or its insurance carrier.4. Make out this claim for compensation and send it to the nearest Workers' Compensation Board Office. (See below.) Failure to filewithin two years after the date of injury may result in your claim being denied. If you need help in completing this form, telephone orvisit the nearest Workers' Compensation Board Office listed below.5. Go to all hearings when notified to appear.6. Go back to work as soon as you are able; compensation is never as high as your wage.Your Rights:1. Generally, you are entitled to be treated by a doctor of your choice, provided he/she is authorized by the Board. If your employer isinvolved in a preferred provider organization (PPO) arrangement, you must obtain initial treatment from the preferred providerorganization which has been designated to provide health care services for workers' compensation injuries.2. DO NOT pay your doctor or hospital. Their bills will be paid by the insurance carrier if your case is not disputed. If your case isdisputed,the doctor or hospital must wait for payment until the Board decides your case. In the event you fail to prosecute your case or theBoard decides against you, you will have to pay the doctor or hospital.3. You are also entitled to be reimbursed for drugs, crutches, or any apparatus properly prescribed by your doctor and for carfares or othernecessary expenses going to and from your doctor's office or the hospital. (Get receipts for such expenses.)4. You are entitled to compensation if your injury keeps you from work for more than seven days, compels you to work at lower wages,or results in permanent disability to any part of your body.5. Compensation is payable directly and without waiting for an award, except when the claim is disputed.6. Injured workers or dependents of deceased workers may represent themselves in matters before the Board or may retain an attorney orlicensed representative to represent them. If an attorney or licensed representative is retained, his/her fee for legal services will bereviewed by the Board and if approved will be paid by the employer or insurance company out of any compensation benefits due.Injured workers or dependents of deceased workers should not directly pay anything to the attorney or licensed representativerepresenting them in a compensation case.7. If you need help returning to work, or with family or financial problems because of your injury, contact the Workers' CompensationBoard office nearest you and ask for a rehabilitation counselor or social worker.This form should be filed by sending directly to the appropriate WCB district office (DO) at the address listed below:Albany DO - 100 Broadway-Menands, Albany NY 12241 (866) 750-5157 (for accidents in the following counties: Albany, Clinton, Columbia,Dutchess, Essex, Franklin, Fulton,Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington)Binghamton DO - State Office Building, 44 Hawley Street, Binghamton NY13901 (866) 802-3604 (for accidents in the following counties: Broome,Chemung, Chenango, Cortland,Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins)Buffalo DO - Statler Towers, 107 Delaware Avenue, Buffalo NY 14202 (866) 211-0645 (for accidents in the following counties: Cattaraugus,Chautauqua, Erie, Niagara)Rochester DO - 130 Main Street West, Rochester NY 14614 (866) 211-0644 (for accidents in the following counties: Allegany, Genesee, Livingston,Monroe, Ontario, Orleans,Seneca, Steuben, Wayne, Wyoming, Yates)Syracuse DO - 935 James Street, Syracuse NY 13203 (866) 802-3730 (for accidents in the following counties: Cayuga, Herkimer, Jefferson, Lewis,Madison, Oneida, Onondaga,Oswego,St. Lawrence)Downstate Centralized Mailing - PO Box 5205, Binghamton NY, 13902-5205 for all DO's in NYC (800) 877-1373; in Hempstead (866) 805-3630; inHauppauge (866) 681-5354; in Peekskill (866) 746-0552 (for accidents in the following counties: Bronx, Kings, Nassau, New York, Orange, Putnam,Queens, Richmond, Rockland, Suffolk, Westchester)C-3.0 (3-09)